(If you’re squeamish, this isn’t the post for you.) There’s a total RIBBFOMP story and photo over at White Coat Rants, hand versus snowblower. If you’ve always wondered what the tendons look like that allow your fingers to flex and extend, but never wanted to take the anatomy class, there’s a perfect specimen in the post. Wow.

The rumors of my demise have been greatly exaggerated, even though my first night of call as a sub-intern was incredibly, incredibly painful. It’s scary to actually admit it, but I… kind of enjoyed my Internal Medicine sub-internship. Yes, I know, this is crazy talk, especially having found my prior medicine months a bit slow, but the constant hypervigilance required to make sure all your patients’ labs get drawn and studies get done is, in a small, small way, similar to the constant nature of the ED.

I enjoyed it so much, and felt so comfortable managing the patients there that I even wondered for a few minutes, “Am I going into the wrong field?” Of course all my medicine colleagues asked me the same thing, and always had their own opinions about Emergency Medicine (I’m used to getting ragged on by pretty much every service by now, so it’s fine).

Calls went incredibly smoothly–probably another reason I enjoyed the month so much. We only capped (received the full number of patients we’re allowed to have) twice in the entire month, once on our first day, and the other we’d capped by 11am, since most of our patients came in overnight and were already tucked in by a fantastic night float resident (thank you, Cheryl!). Taking a note from the ED playbook, I was king of dispo, able to discharge half of my patients by post-call time! (Which often makes you wonder if they needed to be admitted in the first place.)

I definitely learned a ton, and feel comfortable writing diet and DVT prophylaxis orders now. Overall, a really great month.

I think the deal-breaker, however, is summed up today in clinic. I was reading the latest ACEP Newsletter. In the Tricks of the Trade session (written by an awesome mentor of mine, Dr. Michelle Lin!), she mentions unique uses for wall vacuum suction, including how to remove a foreign rectal vegetable using vacuum tubing and bulb suction. What other specialty talks about that in their monthly newsletter?

Shadowfax’s hilarious and freaking bizarre story of a guy seeing Christmas elves reminds me of a patient 2 months ago who, when asked if he knew why he was in the hospital, answered, “I’m here for a meat inspection.” He told this to multiple people.

And my roommate’s girlfriend had a patient who, when asked the date, would frequently answer “6007″ for the year.

(Update, I take that back, my best one-liner was in the ER awhile back. The chief complaint, which I’m sure the triage nurse got a kick out of writing–since she’d normally just write “altered mental status” was “911 called by roommate, patient was meeowing like a cat in his room.)

How it works in the ER, because it’s all shotgun medicine. Talk with patient, ask questions, feel belly. Most of the time the patient is waiting is either because there are sicker patients, you’re doing a procedure, or you’re playing phone tag or following-up on labs that are pending or didn’t get sent. Great writeup.

(Actively bleeding through and through lacs (ie: they go thru the skin and all the way thru the lip and gums into the mouth) are a pain in the ass to close and close well, especially when they don’t respond to lidocaine with epi! That being said, I think I did some pretty good vermillion border work, even with the crappy throwaway instruments and blood everywhere.)

Resident: “My patient snorted 3 grams of cocaine today. That seems like a lot. Is that a lot?”
Attending: “I don’t know, it seems like a lot.”
Me: “Isn’t an 8-ball like an eighth of a gram or something? So that’s like 24 8 balls?”
Other Resident: “How much did Al Pacino snort before he killed that guy in Scarface?”
Clerk: “Oh, it was a lot, cause it was in a big pile, then he cut it into three lines.”
Resident: “You sure know a lot about Scarface.”
Clerk: “It was just on TV 2 days ago!”
Attending: “I guess it just depends on how wide your lines are.”
Me: “And how long they are.”
Resident: “So… 3 grams, is that a lot?”
Everyone: “No idea.”

So there you go. And much less than that is enough to give you a stroke or a heart attack, because cocaine causes spasm of your arteries and cuts off blood supply, so not only be careful, don’t use it.

Dearest Mayor Newsom, could you please remove the crazy pills from the water?

The ED was like I’ve never seen it last night, just busy to the brim. And on the drive home, 7, yes, SEVEN people ran across the street in front of my car. They were just *asking* to get a PVA.

And to my patient who the deputies dropped charges on and you pulled out your IV and left, after I did all this work-up AND made the diagnosis of hyperthyroidism based on history alone, with a very low TSH and a very high free T4, you really should have stayed to at least get your diagnosis. I was proud of making it, and you’d probably feel better sooner rather than later if you had gotten hooked up with an outpatient provider. Sorry dear.

Random ED terminology I’ve made up (feel free to add your own):

Laction: The act of suturing/stapling/closing a laceration. “Man, I’ve had a lot of laction today.”
Awheezile: Like afebrile, but for wheezing. “Yeah, this patient with asthma was wheezing really bad, but after a neb, he’s awheezile.”

The season finale of Lost was amazing, but could we get some wound eversion for Jack’s laceration repair, TV ER doctor? Hell, that little thing could be dermabonded. And while we’re at it, you might not want to use absorbable, practically transparent suture since those need to come out in 3 days to prevent scarring. Snark off.

Shadowed/eavesdropped on calls today at the California Poison Control Center, which was pretty cool. The center here in SF shares the duties with 3 other centers in the state, operating the 24 hour, toll-free number to answer pretty much any question and either make sure people get the right treatment or some needed reassurance. Each state has its own poison control center and the people are incredibly helpful, knowledgeable and friendly–definitely call if you have any questions.

My one experience with it involved my mother making some sort of pasta or tuna salad, while also getting out some hydrocortisone cream for a rash or something, with a tiny bit of the steroid cream ending up in the bowl. Don’t ask me how this happened. I just remember my brother and I freaking out and SCREAMING for her to throw out the entire bowl of food, not wanting our mother to die. She called poison control and they said it would be fine (she’s a nurse so she knew this anyway) but I think we put up such a fit she tossed it anyway. (Or at least she told us she did.) So everyone does silly things, and children eat everything. No matter how silly, it’s no reason not to call. The call centers have heard everything.

Dad: Hi, my child just ate some Play-Doh.
Pharmacist: How much?
Dad: Like half a can.
Pharmacist: Okay, he or she should be fine–
Dad: Oh, wait, nevermind, he just had it in his hand.

Caller: I know this is a line for humans, but my puppy just ate some pills.
Pharmacist: Okay, well, I’d recommend calling your vet. There is a Poison Control Number for Animals, but they charge $55 per call.

Caller: I made some chicken chili last night, and left it out last night. Can I eat it?

Most calls dealt with toddlers eating pills. One “licked the coating off a bunch of Advil and Tylenol.” One important point: Tylenol is actually incredibly dangerous in overdoses–which is hard to do unintentionally in adults–but isn’t so difficult for small children, since overdoses are generally based on weight. Tylenol in overdose has been bad enough to cause patients to go into liver failure and require a liver transplant. Keep pills out of the reach of kids!

Oh, interesting fact: Those little freshness packets in shoe boxes that say “don’t ingest?” They’re just silica, and non-toxic. It’s like eating sand, apparently. (This is not medical advice!) Update from the comments:: Silica gel, the desiccant in “freshness packets,” isn’t always harmless. Sometimes it’s packaged with a moisture indicator and some of those are quite toxic.

I’ve been watching Grey’s Anatomy to relax in my few hours of freedom per day, and I must say, nurses totally get the shaft on the show. Addison is always rooming patients in the ER, checking vitals, and hanging fluids, as if the physicians on the show are these solo practitioners who can do everything for everyone (surgical interns staffing a free clinic, ha!)

ER nurses can laugh with the best of them, and are incredibly fun to work with when the patients are stable. They’re even more amazing to watch when patients go bad. One patient went from looking mildly uncomfortable to coding (needing CPR) in the span of about 3 or 4 minutes, and just like a switch was flipped on, the nurses swooped in and knew exactly what to do. Two secured IVs, another started documenting, and a fourth was pulling meds. I’ve seen the phenomenon a number of times now, and it’s really, really impressive. The teamwork is fantastic. One of the reasons I love the ER.

I remember a patient once asking a Peds nurse why he went into nursing. His reply: “I wanted to help patients. Doctors diagnose patients, but it’s the nurses that actually treat them.”

Already learned how to put someone in restraints and tie them down, saw a patient from the county jail, and re-did an IV on an altered patient who had already ripped it out twice. I was also told to “fight for a suture room and grab it before someone else does.” Grabbed my patient, maneuvered her bed around the drunk man who had urinated in his bed and the onto the floor.

This month is going to be awesome. And crazy.

Possible theme for the month, advice given to me by an attending today: “Better to ask for forgiveness than permission.” (Did I mention I can write my own orders?)

Manch Medic’s post reminds me to ask: Any tips from EMers on transitioning to a week of night shifts? I’m incredibly excited to dive back into clinics with another ER month next week, beginning with a week of 10pm-6am shifts. Sleeping suggestions, napping suggestions, caffeine suggestions? Thanks in advance.

Clutch quote from an OB resident 3 weeks ago that’s still been bothering me, in reference to a patient with metastatic cancer who was in pain and needed a CT scan but was refusing contrast:

“I am so sick of these patients. Just suck it up already and deal with it. God.”

If you’re ever working with me, and I ever say anything as remotely cruel and disgusting as that about a patient, especially one with metastatic cancer all over the place, please, please, sock me in the gut, or slap me, or something. There’s ranting, and there’s bitching, and then there’s just plain inability to have any sort of compassion or caring for your patients.

I feel guilty that I didn’t speak up and put the resident in her place. Granted it was 3 residents versus one med student, but I wish I would take the right path rather than the easy one a little more often. Sigh.

Have you ever read a comment someone posted on your blog, and then they double-dipped and turned it into a post on their blog, so you decide to triple-dip and post their comment from their blog from your blog back onto your blog?

I was intending to be snarky with my “Get Out of My ER” title, as I am far from the jaded, paternalistic assholery that would say such a thing. I got lots of great responses, everything from the short and sweet to the longer explanation to the scolding for ignoring a possible influenza to the “don’t do that you’ll just make trouble for yourself.”

I think Nick’s wins, or is at least the closest to what I try to do. I believe as ER professionals we’re not only supposed to evaluate, treat and determine dispo, but we’re also supposed to educate–all physicians are. We know the most about the human body out of the entire society, and it’s our job to not only provide education about the body, but also about normal and healthy.

This mostly happens seeing pediatric patients, and often it seems that the pediatric ER visits are frustrating for all parties involved: docs, nurses, staff, parents, and the kids themselves. Kids are, in general, healthy and resilient. And most pediatric ER visits that I’ve seen are in general, healthy.

These kids are fine. They have a cold, or a GI bug. They are eating well, peeing and pooping fine, they’re active and well-hydrated. Their vitals are all stable. Sometimes they have a fever.

These are kids that will, in general, do fine at home, or at the very most, need a sick child appointment at the pediatrician. It’s not an emergency. It’s not life-threatening.

Have things changed? Has it always been like this? If not, where’s this coming from?

Or how about the breakup of the extended family unit? When you don’t have grandparents around or aunts or uncles or friends with older children who can re-assure a parent, maybe they’ll take them to the ER more often?

Or lack of access to pediatricians? And maybe lack of health insurance? More and more patients tell me that the advice nurse in the pediatrician’s office told the parent with the kid with a cold and a 101 fever to go to the ER, since the pediatrician was booked solid for the day.

The “I want it now” culture? An inability to just let a child be sick for a week or 10 days? An inability to be patient?

Cultural norms? I read somewhere that seeing a doctor in Latin and South America generally means spending hours in a waiting room, so it’s perfectly normal to just go to the closest, most accessible doctor instead of calling one’s pediatrician to schedule an appointment.

Lack of education about what are normal things for a sick kid to do, and what are abnormal ones? Maybe it’s just that the population has grown, and we haven’t kept up to provide the resources to educate them all?

Sometimes I wonder if it wouldn’t be more efficient to have the triage nurse take a kid’s vitals, and watch the kid in the waiting room, and if he or she looks fine, suggest heading to the local clinic–the wait is probably shorter, anyway.

A call to all the ER docs out there: how do you tactfully, non-insultingly tell patients who come in with minor complaints, “You’re fine, go home, this is not an emergency, you should not come to an ER for a problem like this?” (For example, kid with a cold and low grade temp who is otherwise playful, active, eating and drinking well, with good sats, etc.)

It’s funny what people can live their lives with thinking it’s just normal–that everyone operates on the same assumptions. If it’s always how it’s been for you, how can you know any better?

Three patients reminded me of this fact.

The first is a teenage Russian mother. Her 4-month old adorable little baby had a terrible case of eczema. She was seen in the ER a week ago, given some medications, and told to get a pediatrician at a local clinic. A week later, she shows up in the ER again. For the eczema. There are mutterings and under-the-breath annoyed words spoken–what the hell is she doing back here with her baby’s eczema? This is not an emergency. We ask her why she didn’t go to the clinic, as instructed, and she says, “I went there and they said I was going to have to wait 3 hours.” We say, “Well, yeah, you’re going to have to wait, it’s a clinic. But if you make an appointment, you’ll be able to get in faster.” She kind of nods, and we kind of stand there for an extra beat, hoping she gets it. We re-iterate to her that we cannot manage the kid–she needs to see a dermatologist, and get a referral from her pediatrician. Once we explained how referrals work, I think she figured it out.

My instincts were to think, “What, is she stupid, does she not understand how doctors work? Does she not realize this isn’t an emergency? Is she just lazy and abusing the system?” But the more I thought about it, I think she just honestly didn’t know how the medical system works. She didn’t know how to get care, or how to get a pediatrician, or get help for her baby, so she went to the one place she knows there will be doctors: the ER.

The next is a 30-something administrative clerk at a law firm, with an exquisitely tender ingrown toenail. Ouch. She tells me she gets these rarely, and I ask, “How rare is rarely?” and she shrugs, “Oh, about once a year or so.” (She usually gets a pedicure, but was too busy with the holidays to get one this year.) She has special clippers to prevent it from happening. She is bewildered when I tell her that I think that’s pretty frequent–that most people don’t get them so regularly. “They don’t?” I tell her there are ways to remove the nail matrix causing the ingrown toenail, and suggest she ask her doctor about it.

Again: she’s had ingrown toenails since she was a kid, and just thought it was your normal, everyday thing. Maybe her family had them too, so the notion was enforced. (This also supports my theory that “All families are weird,” because you’ll hear someone describing what traditions they do for Christmas, or birthdays, or whatever, and you think it’s totally bizarre because it’s not how your family does things.)

The last is a 24 year-old student with a chronic cough. He’s got a pretty good family history of atopy and a brother with asthma. He describes the coughing fits as generally after exercising, like running on a cold day–but sometimes even after weird things like drinking a Slurpee too quickly. They last for a good hour or so–but as far as he can remember, he’s had them his whole life.

Now you may be thinking that these patients are just uneducated about their disease, or don’t have a whole lot of medical knowledge or background. But this last one is nothing of the sort. Turns out he’s a medical student. Turns out his father is a doctor. His mother is a former nurse.

Turns out that it’s me, and my cough-variant asthma.

I had no idea–no freaking clue–that other people didn’t cough and cough and cough like me–I just thought that was normal human behavior, a normal reaction to exercise, or cold air, or… Slurpees. It wasn’t until I was reading about asthma that it finally hit me, Mr. Medical Student.

Don’t make assumptions about what you know, what you think you know, or what you think your patients know. Educate, educate, educate, and if something doesn’t seem “normal” or “right,” there’s probably a good reason (or maybe you’re the weird one, and there’s no good reason at all).

Some of these are inherent to going to an Emergency Department; others are just the difficulties of clinical medicine.

Your doctor will assume the worst. This is something patient’s really don’t get, and only recently have I started to get myself. Emergency medicine trains a person to rule out the really deadly, nasty stuff. We treat, we diagnose when we can, but above all, we make sure you’re not having a heart attack or any other potentially deadly disease. Let’s remember, of course, that you the patient, have generally gotten yourself to an emergency department for some reason–and we’d like to figure out if it really is an emergency. For this reason, my lists of possible diagnoses have changed.
I saw 5 kids a day with nausea and vomitting on my Peds rotation, and we primarily made the diagnosis of acute gastroenteritis and sent them on their way with fluids and education. But in the ED, it’s not just the stomach flu. It’s an appendicitis, or an incarcerated hernia. (I realize I should have been considering this more often in the outpatient clinics, but my awareness is definitely more heightened.)
The correlate of this emergency paranoia is that you, the patient, will get poked and prodded much more than you would if you just went to your outpatient doctor. Your stomach ache isn’t just a stomach ache in the ED; it could be a heart attack, an aortic dissection, pancreatitis, a kidney stone, or an early appendicitis. (And this isn’t just exaggeration on the part of the ED–there’s many people who have heart attacks who don’t have the classic “crushing chest pain.”) It’s almost like once you’ve got a bed in the ED, you’re stuck there until we’re done with you. I know this sounds terrible. It probably is. But think of the physician’s responsibility for his or her patients: you’ve gone to an Emergency Department and want his or her help. Is it worth drawing blood and urine on patients who might have a heart attack (but might not) if you catch more heart attacks, or other deadly conditions? I’m inclined to say yes. I’ve been in the ED two weeks and I’ve already had at least one patient with a heart attack that I never would have suspected. She had no chest pain, but had a very significant history of heart problems. (Note: this does not mean go to the ER for a heart attack every time you have a stomach ache! Do not tell them I sent you!)

On to number 2: You will wait. And wait, and wait, and wait. We don’t see people in the order they came in, like they do in your doctor’s office. We see them by seriousness of illness, and then by when they came in. If you’re next up to get a bed, and then a guy comes in with left-sided weakness, and another comes in with a broken arm, and then the clerk announces that a 3-person trauma from Life Flight is on its way, you’ve just been bumped. Again, emergencies go first.
And even if you’ve got a bed, if someone more sick comes in and requires your doctor’s attention, that patient’s care goes first. Your labs may be done and your CT scans and drugs may be finished, but your doctor’s busy managing someone that’s not breathing. You wait. Is this suboptimal? Yes, but if you were the patient that wasn’t breathing, you’d want it that way, too. Have your partner or spouse or friend bring a book or magazine for you.

If you don’t speak English, you’ll likely wait longer on average. I can’t imagine what it’s like in an area of the country that’s pretty homogenous. Even in central California, which has an enormous immigrant population, translation is a problem. Even at one of the many hospitals we rotate through, which has 24-hour, live and breathing translators, they still have to be paged, or they’re currently seeing another patient. I had several non-English speaking patients, both in pain, but without knowing what their problems were, we had a difficult time treating their pain adequately. I’m heading to Guatemala next year to get my Spanish up to fluency standards, but still most doctors only speak two languages: English and medicalese. (There are many problems with using kids as translators as well–if they speak one language at home and English at school, they may have never learned medical words like pancreas or palsy or gall bladder, for example.)

You don’t get much privacy. Your neighbor can probably hear you when you tell the doctor you’ve had STDs in the past, or abortions, or use drugs, or whatever else you’re supposed to be ashamed of. They can probably hear your diagnosis, your intimate, private details. And it’s probably safe to say that the ED isn’t the best for grieving, or talking about death, or anything solemn and serious. There’s no peace, nor quiet, in the ED.

For next time: the great things about the ED, of which there are many.

These are the words that start to change my diagnosis from “kidney stone” to “drug-seeking.”

Two weeks ago, I pull back the curtain, introduce myself, and see a woman writhing around in (supposed) pain, tears in her eyes. She tells me she’s had 4 kidney stones previously. They’re all uric acid stones, which are generally undetectable on X-ray. That she went to a urologist, was on allopurinol, but stopped it two months ago. This all happened in Texas. She tells me where her pain is, and that it radiates to her back and down to her groin. “Kidney stone! It’s a kidney stone!” I tell myself. I am brilliant. I examine her, find some tenderness on her right flank. Her urine has already been sent to the lab. I tell her I’m going to go talk to the doctors to discuss what we can use for pain control. She warns me that she is allergic to aspirin and Tordol–a strong pain reliever but not a narcotic. (Think super-Advil.) Her mouth swells up when she takes either of these. “What terrible luck, a woman with chronic, painful kidney stones and allergies to common pain relievers!” I think. She then finishes her pain medication story: “Whenever this happens, I usually get dilaudid and phenergan, and sometimes ativan because I have anxiety attacks.” And it all goes downhill from there.

I pause, skepticism and cynicism running through my mind, but I give her the benefit of the doubt. Assume nothing, I remind myself. Moments later, the patient’s nurse chases after me in the hallway. “She’s a frequent flyer here, you know. She was just here 2 weeks asking for the same thing. And I guarantee you next she’ll ask for Fentanyl.” Add more skepticism to the pot.

So we check her name–first time she’s been at the hospital. Maybe she’s using an assumed name? We check her urine, and it’s strongly positive for both blood (going along with the stone story) and white cells, indicating an infection. We’re stuck–her story and labs say maybe she’s telling the truth, but everything else is leaning toward malingering. So we start antibiotics for her infection, give her yes, some dilaudid and phenergan for pain control, and I tell her she’s going to need a CT scan. We get the scan setup, and she continues to ask for more pain medication–”It helps for like 2 seconds and then goes away!” Just when she’s ready to go to the scan, she starts asking for some ativan (similar to valium) for anxiety, because she gets claustrophobic in the scanner. We point out her head won’t be in the scanner, just her abdomen and pelvis. She continues. We tell her she’s already had a good deal of pain medication, and we don’t want to continue giving medications that could suppress her respiratory rate. She starts crying, and starts loudly asking, “Why can’t you just help me?? I’m in pain here, I’ve never been treated like this before.”

My resident pops into the room and helps with the authority bit, and later tells me she recognizes the woman too.

She misses her chance in the CT scanner, so we wait. She, as the nurse predicts, starts asking for Fentanyl, a very strong narcotic. She then starts cycling–”I’m in pain,” then “I’m nauseous!” then “I have a headache,” then “I have a sore throat,” then “I’m anxious,” each time asking for a different medication for her symptoms. She finally just goes to the CT scanner, but leaves the scanner with an anxiety attack.

If the woman does have a stone plus an infection, the infection could start climbing up toward her kidney. She could get an infected kidney, could get septic, could die. I discuss this at length with her. I tell her we believe she needs this scan to make sure she doesn’t have such an infection. She gets upset again and says she wants to leave. (I’m leaving out plenty of copious details, as this dragged on for hours.) We talk about why this is a terrible idea, but she wants to leave anyway. I go get the paperwork for her to sign to leave Against Medical Advice. I come back and note 2 things: her hand is down near her genitalia, under the blanket. (This was the case the last time she was here.) She’s either masterbating or giving herself an infection. I try my best to ignore this, which is totally disgusting, and hand her the paperwork to sign. She can barely grab the pen, she’s so sleepy and out of it from the narcotics. She’s still complaining of pain. She signs and initials here and there, and finally leaves. (I throw away the pen.)

Meanwhile, we have 10 other patients that have been waiting to be seen by a doctor; she’s wasted a bed for at least 4 hours. I’m angry, frustrated, and annoyed–and the rest of the nurses and doctors are, too. I sigh, quickly eat a granola bar for dinner, and pick up my next chart: a woman that’s been waiting 6 hours in the lobby to be seen for a simple clogged NG tube.

Update: I forgot to mention the final kicker–the woman asked for “Vicoprofen,” which is like Vicodin, but has ibuprofen in it instead of Tylenol, which is in vicodin. (She says the Vicodin makes her throw up.) My attending was smart, and realized the real reason she asked for the vicoprofen: it has a larger amount of narcotic in it per pill than the vicodin. Another trick of the trade, apparently.

I have a habit (don’t we all?) of walking around the ER (especially in the trauma bay) to see what’s happening with patients. It’s all the rubbernecking goodness without wasting any gasoline. You see someone with some big gashes in his forearm, or an arm that’s totally deformed, and you think to yourself, “Man, that must hurt like hell. That sucks. Glad that’s not me.”

This same sick curiosity happened last week with a jaundiced patient. This guy was the brightest yellow I’ve ever seen in my life. The whites of his eyes were fluorescent-highlighter yellow. I had just caught him out of the corner of my eye, and the “Oh man, that really sucks” thoughts came flowing right in.

But then I did a double-take–I knew the guy. He was actually one of my favorite patients that I had taken care of back in February. And I felt really sick for giving him such a cursory thought–and one of pity at that. I went over and we talked for a few minutes–that I was sorry to bump into him in such circumstances, how his kids were doing, how he was feeling.

And then the conversation quickly went from superficial to serious, confiding in me that he didn’t want to be one of those poor guys that dies on the transplant list. His eyes filled with tears, and a lump grew in the back of my throat. I touched his forearm, and said I didn’t want that to happen, either. Right after that the transporter came in to take him to his bed in the hospital, and I said goodbye for the time being.

While I don’t know if I’ll ever be able to get the rubbernecking thoughts from my head, I know I’ll be less superficial with their impact–it’s not just that an arm is broken–it’s that the person’s arm is broken.

Enjoying emergency medicine, but we’ll see after this 4-day stint is up. Finished a shift last night at around midnight, now I’m back on today at 10am, then 8am on Sunday, then a day off. Our clerkship director is right–working an 8 hour shift in a busy ER is like working a normal 16 hour shift on call.

With states now allowed to make changes on eligibility requirements for Medicaid, West Virginia will be requiring many beneficiaries to sign a contract in which they promise to use the ER only for emergencies and to keep their doctors’ appointments. Failure to do so will result in loss of benefits. And why not?

Medicaid spending is out of control and is squeezing state budgets. ER visits for non-urgent conditions are hundreds of dollars more expensive than an office visit so that seems like a good place to start to try and control costs.

He goes on to note that low-income people disproportionately make up a good percentage of ER visits, and goes on to say that “only about 16% of ER visits among all patients are considered to be true emergencies so the potential exists for a substantial reduction in unnecessary ER visits among Medicaid beneficiaries.” In the comments, another doctor, Flea, agrees.

I’ll throw another mess into the pot here before drawing my conclusions. A retired orthopod, Dr. Thompson, frequently comments on my blog, and left this zinger today: “I personally see nothing wrong with health savings accounts and allowing patients to be in charge of their health care decisions.” Wha-wha-what?

What is it with these doctors? I’m at a loss. We’ll go point by point here:

Medicaid is broke. Check.

Poor people use the ER more often. I’ll assume for the sake of argument this is true. Check.

Only 16% of ER visits are truly emergencies. Now things get murky. The study Dr. Rangel is quoting seems to be looking at end-diagnoses, not symptoms. In my 4 ER shifts, maybe out 20% of the people I’ve seen have been truly emergencies or urgencies. However, the people’s symptoms have been a much higher percentage of possible emergencies! Sure, you see 10 chest pains for every 1 heart attack, but how the hell are our patients supposed to know that? A patient got poked in the eye pretty bad. Should he wait until morning? Or go into the ER? A patient feels nauseous and light-headed, and has one episode of shaking. We find nothing wrong with him, but I’d get myself to an ER immediately, too!

Next up: If we follow the “poor people” line, we’ll go ahead and assume they’re probably also the least educated, too. So now we’re asking the least educated of our population to properly differentiate between emergent and non-emergent. (Some things are “duh,” but honestly, most of them aren’t.) The rich get richer, and the poor get sicker. (As a commenter noted on Dr. Rangel’s site, perhaps Medicaid patients go to the ER more often because so few doctors see Medicaid patients anymore.)

If we want incentives and disincentives (carrots and sticks), let’s make an actual, viable system. If you go to the ER now with your Medicaid or whathaveyou, you may get a bill for several thousand dollars. Ha! That’s what you make in 3 months! What a joke! In a perverse system like this, people will respond just as perversely. No doctors at clinics? Ridiculous bills? Might as well just use the ER when I need it, since the whole system’s a joke.

And finally for Dr. Thompson’s doozy: of course you don’t have a problem with Health Savings Accounts and people making their own health care decisions. You know exactly what decisions to make–you’re a doctor! That’s what you’re supposed to do–make health care decisions. But as I’ve said before, people that need health care urgently pick the closest hospital; no one bargain shops (as if you could get prices anyway). And which patient has the time and energy (and background) to research the costs and benefits of a certain study, and to interpret what the research actually means clinically?

Can we please, please, PLEASE stop with the patchwork nonsense where we try to eliminate limit health care for the poorest and sickest and drive all the burden onto our already-burdened-with-their-illness patients? Can we see the forest amongst those trees? Can we see that hitting one group with this policy or that one will only create more burden in the long run, and that the only real solution is one that affects us all? Single-payer, multi-payer, I don’t even care at this point–I just wish people would see the big picture. (And no, not the big picture of your specialty. Zoom out one more time. The big picture of everyone.)

I’m sitting there, talking with a 40 year-old woman complaining of lower back pain who had a kidney transplant, and then she adjusts herself to try to get comfortable, and shakes a couple times. She starts gasping for air; she is unresponsive to my questions. I immediately call for help, and a nurse comes in. Neither of us can get her to respond, and her eyes are glazed over. The nurse goes to get the attending, who comes in. We’re having trouble getting a good O2 sat on her (that gives us a rough idea of the oxygen in her blood), and once we do, we realize she needs to be intubated to help her breathe. We intubate, and then have to start CPR; she now has no pulse. Her blood pressure is dropping. We code her for 11 minutes. Her pulse comes back, and she’s maxed on the medications for blood pressure support. Her heart on ultrasound is pumping, but barely.

I have my hand on her femoral artery. We lose her pulse again. We code her for 24 more minutes, and eventually the family decides to do comfort care and have some time alone with her. We lose.

I could go into all my analysis of how my resident did a great job and set a good example of following the basics–Airway, Breathing, and Circulation. But something scares me more than not knowing exactly what to do when this happens next time.

What’s really bothering me is how okay with it I feel. That we spent 2 hours trying to bring someone back to life, that she crashed right in front of me–basically died right in front of me–and I was totally okay with that. That 5 minutes after it was over, after I finished writing up what happened, I just went about my business and picked up the next chart. I moved right on.

I keep waiting for some delayed grief reaction or something, like I’m going to be just walking down the street and suddenly feel really sad or something, but it’s not happening. I mean, this person I just met died, but I’m not all that upset about it. Maybe I just didn’t know her long enough to need to grieve about her. Maybe I somehow knew that after the first code, things weren’t looking good, and I didn’t have much hope when the second one began. Maybe this makes me a great, objective, detatched doctor. Maybe this makes me a terrible, distant, detatched human. I don’t know.

I’m hoping that either my over-analysis of this event over the past week is my grief reaction, or that whatever part of me I think I’m currently missing can come back, because it seems pretty damn ironic if I’ve somehow lost my compassion and empathy during the practice of medicine. Never saw this one coming.

So Psych is over. I really, really liked it, and found the patients fascinating–how someone seemingly “normal” can become psychotic, hearing voices, believing strange things–and not even understand that the things they hear or believe are abnormal–is surreal, frightening, and incredibly terrible. I’ve also known people that think mental illness (especially depression) is a bunch of crap, that people should just suck it up–and these are clearly the people that have never seen depression. They’ve seen sadness.

Interesting cultural-cum-insurance caveat (how often do you find those!?): the psych service sees a good number of Stanford undergrads (at least 1 per week) in the locked unit for mania, psychosis, etc. One of the major problems is insurance, as some programs have terrible mental health coverage and won’t pay for hospital stays or outpatient programs. Notoriously difficult are students from Asia with insurance from their home country; there’s a pretty strong disbelief in the notion of “mental illness” in many Asian countries, so often these students have absolutely NO mental health coverage whatsoever. Disaster.

I will miss my team, as psychiatrists tend to have just the right amount of quirk for my tastes, and I will definitely not forget Gertrude walking down the halls screaming the most random of things, “These are the poisonous snowflakes of Santa Claus!” “I need a silver bullet… because I have acne! Zits! Pus! Pustules!” I would seriously just lose it in the halls. It was kind of bad. She later grew fond of me, “Hello gorgeous, you’re quite a ticket!”

Psych is great, but I always had something of a hard time with treating the black box that is the human mind. I’m sure it’s the art of the practice, but I’m so used to having more data, I guess. I also felt a little weird using my own life or experiences as the norm by which to judge a patient’s thoughts, actions, behaviors. I may pull off normal well, but I’ve had my share of issues and poor coping mechanisms, not to mention my, uh, “unique” personality traits and general dorkiness.

I’ve found that I really enjoy the psychosocial of medicine–it’s why I liked psych so much, it’s why I really enjoyed adolescent medicine. And I think it’s what draws me to the ED (Emergency Department, the correct way to refer to the “ER” now), too. I love the idea that you can walk in and see anyone, with anything, speaking any language. It’s a real cultural mashup.

This is also the reason that I’m nervous tonight about my first shift, tomorrow afternoon. I could see anything walk in the door. And it’s been a couple months since I’ve been on adult medicine. Granted stuff usually comes back pretty quick for me, but the idea that I could be seeing just about anything scares the hell out of me. (I of course assume I will only see very scary, serious things, no colds or chronic lower back pain.)

So there we are. The ED tomorrow, working my butt off. Back to studying for now.